Medical Documentation of Non-Accidental Trauma

Learning Objectives
Recall documentation principles that are critical when airway, head, or neck findings raise concern for non‑accidental trauma
Explain how objective, timely documentation supports safe airway decision‑making and mandated abuse reporting in critically ill children
Apply neutral, descriptive documentation practices to airway‑related findings (e.g., facial bruising, oral injuries, altered mental status)
Analyze how documentation errors or omissions can compromise airway safety, multidisciplinary care, and legal defensibility
Evaluate clinician responsibilities for reporting, photographing, and recording findings when airway management occurs in suspected abuse cases
Author(s)
Kelly Haynes, ADN, JD
Risk Manager | Dana Farber Cancer Institute
Traci Wolbrink, MD, MPH
Co-Director, OPENPediatrics; Co-Director, Center for Educational Excellence and Innovation; Program Director, Pediatric Critical Care Medicine Fellowship; Senior Associate in Critical Care Medicine | Boston Children’s Hospital
Associate Professor of Anaesthesia | Harvard Medical School
Citation
Haynes K, Wolbrink TA. Medical Documentation of Non-Accidental Trauma. 1/2015. Online Video. OPENPediatrics. https://learn.openpediatrics.org/learn/course/internal/view/elearning/3054/medical-documentation-of-non-accidental-trauma.
